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Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to failure to maintain a pair of 1 ½-hr fire rated doors in 2-hr fire-rated occupancy separation between the Medical Office Building (MOB) and hospital in accordance with NFPA 101 19.1.2.1, 8.2.3.2. This deficient practice affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 3:48 pm that one set of 1 ½-hr fire-rated cross-corridor doors in the 2-hr fire-rated occupancy separation between the Medical Office Building (Aylward Building) and hospital (i) did not have an astragal at the meeting edge, (ii) lacked bottom bolts for latching; and (iii) had some holes on the door indicating removal of bottom bolts. The doors were located near the North Pavilion Entrance and the MOB 151.

The above observation was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with the facility management manager, Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to lack of smoke detector in two spaces open to corridor in accordance with NFPA 101 19.3.6.1, 19.3.6.2.2. This deficient practice affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff B (facility management manager), Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/9/2010, Surveyor 12316 observed between 2:20 pm and 2:45 pm that two locker/solarium spaces located at each end of the 6th Floor 1969 building were neither separated from corridors with smoke-tight corridor walls, nor provided with smoke detector coverage.

The above deficiency was acknowledged by the facility management manager, facility management supervisor, security supervisor, and environmental safety officer on 2/9/2010 at the time of discovery, and confirmed with the facility management manager, Staff A(quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors due to lack of automatic flush bolts on inactive leaf of double leaf corridor doors in two locations in accordance with NFPA 101 19.3.6.3.2, 19.2.2.2.1, 7.2.1.5.4. This deficient practice affected 2 of 29 smoke compartments in the facility.

Findings include

Item 1. During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2:30 pm that the inactive leaf of double leaf corridor doors in the Waiting Room C124 of the Orthopaedics Plus area did not have an automatic flush bolts. Lack of automatic flush bolts does not ensure that the doors are operable with " not more than one releasing operation " for a safe egress from the Waiting Room and to quickly close doors to contain smoke/fire in the room in the event of fire.

Item 2. During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2:44 pm that the inactive leaf of double leaf corridor doors in the Memorial Conference Room C109 on the 1st Floor did not have an automatic flush bolts. Lack of automatic flush bolts does not ensure that the doors are operable with " not more than one releasing operation " for a safe egress from the Conference Room and to quickly close doors to contain smoke/fire in the room in the event of fire.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients and staff due to failure to protect openings in hazardous areas in two locations in accordance with NFPA 101 19.2.2.2.6. This deficient practice affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/11/2010, Surveyor 12316 observed at 2:58 pm that two doors of the Storage Rooms S028 and S029 in the Basement were mechanically held open and not with electro-magnetic held open devices that release the doors upon activation of the fire alarm or sprinkler system in accordance with the requirements of NFPA 101 19.2.2.2.6 and 7.2.1.8.2. Such held open devices do not automatically release and close the doors to prevent smoke transfer from the storage rooms into corridor in the event of fire.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer on 2/11/2010 at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to the failure of one smoke barrier to extend to the roof deck above in accordance with the NFPA 101 19.3.7.3 and 8.3 requirements. This deficient practice affected 2 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), Staff E (environmental safety officer), and Staff J (electrician) on 2/9/2010, Surveyor 12316 observed at 11:45 am that the smoke barrier located adjacent to the Gift Shop and the Orthopaedics Plus on the 1st Floor did not fully extend to the roof deck above, and the portion of smoke barrier wall in the interstitial space was not 1/2 hr fire-rated as required.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, environmental safety officer and electrician at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to the failure of one fire-rated smoke barrier door located on the 2nd floor to fully close. This deficient practice affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/9/2010, Surveyor 12316 observed at 1:15 pm that the west leaf of a pair of smoke doors did not fully close and latch, and left a gap of ¾ inch at the meeting edge. The ¾ hr fire-rated door in the 1-hr fire-rated smoke/fire separation wall between Theda Clark Medical Center and another hospital, is required to close and latch.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to failure to protect openings in hazardous areas in five locations with properly functioning doors in accordance with NFPA 101 19.3.2.1. This deficient practice affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), Staff E (environmental safety officer), Staff G (business unit manager), and Staff H (RN, supervisor) on 2/9/2010, Surveyor 12316 observed at 3:59 pm that the Storage Room R137A located across the Decontamination Room in the Operation Room (OR) Suite on the 1st Floor did not latch when tested.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to failure to protect openings in hazardous areas in four locations with properly functioning doors in accordance with NFPA 101 19.3.2.1. This deficient practice affected 4 of 29 smoke compartments in the facility.

Findings include

Item 1. During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2:25 pm that the Storage/Condensate Pump Room in the Orthopaedics Room Suite on the 1st Floor did not have a self-closing device as required. The condensate pump room was also observed to have been used as a storage room;

Item 2. During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2:50 pm that the Storage Room N115B with one work station adjacent to the Gift Shop on the 1st Floor did not have a self-closing device as required;

Item 3. During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 3:48 pm that the Supply Room N145 in the Cath Lab Suite on the 1st Floor did not have a self-closing device. The room had combustibles stored in it and hence was deemed hazardous; and

Item 4. During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/11/2010, Surveyor 12316 observed at 3:50 pm that the fire-rated door of the Medical Records Storage Room N034 in the Basement did not latch due to obstruction caused by the flooring material (carpeting) over the door sill. The combustible carpeting on the fire-rated door sill does not meet the requirement of NFPA 80 1-11.2.4, which requires a sill of noncombustible material.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to one non-latching fire-rated door of the Gift Shop Storage on the 1st Floor in accordance with NFPA 101 19.3.2.5. This deficient practice affected 1 of 26 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2:40 pm that the 1 ½ hr fire-rated door of the Gift Shop Storage on the 1st Floor did not latch as required.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to the failure of one fire-rated door on the 1st Floor to latch in an exit passageway. This deficient practice affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 1:15 pm that a pair of 1 ½ hr fire-rated doors located adjacent to the S128 Room did not latch. The double doors protected an opening in the exit passageway enclosure located between the ICU suite and OR suite.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to (i) failure to maintain one exit access to exits readily accessible in the 3rd Floor near the Birthing Center on the 3rd Floor, and (ii) lack of required headroom of minimum 7 ft in the Medical Records Room and adjacent corridor. This deficient practice affected 1 of 29 smoke compartments in the facility.

Findings include

Item (i). During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/11/2010, Surveyor 12316 observed at 1:20 pm that a pair of ¾ hr fire-rated cross-corridor smoke doors located in Corridor N301 near the Birthing Center on the 3rd Floor had delayed egress locks installed on both doors, and were not operable when tested by a push on the door.

The above stated pair of fire-rated doors in 1 hr smoke barrier wall were not arranged to be readily opened in accordance with the NFPA 101 7.2.1.5 and 7.2.1.5.4 requirements. Hence, the doors in the means of egress Corridor N301 did not readily provide an access to exit stairwells as required. Furthermore, there was no proper 15 second delayed egress signs posted on the doors in accordance with NFPA 101 7.2.1.6.1

Item (ii). During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/11/2010, Surveyor 12316 observed at 3:48 pm that the headroom (ceiling height) in the Medical Records Storage Room with some staff work stations, and in the corridor outside of the records storage room was approximately 6 ft 8.5 in. and not 7 ft as required by NFPA 101 7.1.5 Exception No. 1. The lack of required headroom does not ensure a safe egress from the room and corridor.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to higher than required temperature rated sprinkler heads in the Mechanical Room located above the 1963/69 Building. The temperature rating of sprinkler heads did not conform to the requirements of NFPA 13 5-3.1.4.1 1999 edition. This affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/11/2010, Surveyor 12316 observed at between 11 am and 11:30 am that the Mechanical Room located in the penthouse above the 1963/69 Building was not protected with sprinkler heads of ordinary temperature rating.

The penthouse contains air-handling units, ductwork, circulating pumps, steam piping with no exposed steam mains, or unit heaters, some related combustible storage, such as air filters, and electrical switches and panels. The quantity of combustibles in the room is not moderate or high to classify the room as an ordinary hazard group per NFPA 13 2-1.2, which would have allowed intermediate or high-temperature rated sprinkler heads.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to failure to maintain a minimum of 18 inch vertical clearance below the sprinkler deflectors and above the top of storage in two storage rooms in accordance with NFPA 13 5-5.6 1999 edition. This deficient practice affected 2 of 29 smoke compartments in the facility.

Findings include

Item (i). During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 1:12 pm that the vertical distance from top of storage and sprinkler deflectors in the Clean Equipment and Supply Room in the ICU suite on the 1st Floor was less than 18 inch.

Item (ii). During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2:40 pm that the vertical distance from top of storage and sprinkler deflectors in the Gift Shop Storage on the 1st Floor was less than 18 inch.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with the Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients due to storage of compressed oxygen gas cylinders along with other incompatible materials in a housekeeping closet, and not stored in accordance with NFPA 99 8-3.1.11.2. This affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2 pm that two " E " size compressed oxygen gas cylinders were stored with other non-related materials and combustible items in the Housekeeping closet in the Outpatient Prep/Recovery Suite on the 1st Floor.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with the Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and staff interview, the facility failed to install a floor drain in the emergency shower located inside the Laboratory in accordance with NFPA 99 10.6. This affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2:55 pm that the emergency shower installed in the Laboratory did not have a floor drain to drain the water in the event of emergency use of the shower. The Lab is located in the Basement.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with the Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and staff interview, the facility failed to label the emergency electrical wall outlets in two locations in the ICU Suite in accordance with NFPA 70 517-19(a), and to provide working space in front of electrical switches in one location in accordance with NFPA 70 110-26. This affected 1 of 29 smoke compartments in the facility.

Findings include

Item (i). During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 12:52 pm that the electrical duplex receptacles in two rooms S100 and S103, where critical care is provided to patients, were not identified as to which critical branch electrical panel and circuit breaker the power is supplied from.

Item (ii). During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/11/2010, Surveyor 12316 observed at 11 am that the Mechanical Room with electrical panel and switches, and air-handling units serving the hospital had one cart with a saw stored in front of electrical switches. The object did not provide working space required in front of electrical panels and switches in accordance with NFPA 70 110-26. The Mechanical Room is located in the penthouse above the 6-story 1963 Building.

The above two observations were acknowledged by Staff C, Staff D, and Staff E at the time of discovery, and confirmed with the Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

NFPA 70 110-26.
"Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment ... "

NFPA 70 110-26(b) Clear Spaces.
"Working space required by this section shall not be used for storage ..."

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to failure to maintain a pair of 1 ½-hr fire rated doors in 2-hr fire-rated occupancy separation between the Medical Office Building (MOB) and hospital in accordance with NFPA 101 19.1.2.1, 8.2.3.2. This deficient practice affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 3:48 pm that one set of 1 ½-hr fire-rated cross-corridor doors in the 2-hr fire-rated occupancy separation between the Medical Office Building (Aylward Building) and hospital (i) did not have an astragal at the meeting edge, (ii) lacked bottom bolts for latching; and (iii) had some holes on the door indicating removal of bottom bolts. The doors were located near the North Pavilion Entrance and the MOB 151.

The above observation was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with the facility management manager, Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to lack of smoke detector in two spaces open to corridor in accordance with NFPA 101 19.3.6.1, 19.3.6.2.2. This deficient practice affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff B (facility management manager), Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/9/2010, Surveyor 12316 observed between 2:20 pm and 2:45 pm that two locker/solarium spaces located at each end of the 6th Floor 1969 building were neither separated from corridors with smoke-tight corridor walls, nor provided with smoke detector coverage.

The above deficiency was acknowledged by the facility management manager, facility management supervisor, security supervisor, and environmental safety officer on 2/9/2010 at the time of discovery, and confirmed with the facility management manager, Staff A(quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors due to lack of automatic flush bolts on inactive leaf of double leaf corridor doors in two locations in accordance with NFPA 101 19.3.6.3.2, 19.2.2.2.1, 7.2.1.5.4. This deficient practice affected 2 of 29 smoke compartments in the facility.

Findings include

Item 1. During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2:30 pm that the inactive leaf of double leaf corridor doors in the Waiting Room C124 of the Orthopaedics Plus area did not have an automatic flush bolts. Lack of automatic flush bolts does not ensure that the doors are operable with " not more than one releasing operation " for a safe egress from the Waiting Room and to quickly close doors to contain smoke/fire in the room in the event of fire.

Item 2. During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2:44 pm that the inactive leaf of double leaf corridor doors in the Memorial Conference Room C109 on the 1st Floor did not have an automatic flush bolts. Lack of automatic flush bolts does not ensure that the doors are operable with " not more than one releasing operation " for a safe egress from the Conference Room and to quickly close doors to contain smoke/fire in the room in the event of fire.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients and staff due to failure to protect openings in hazardous areas in two locations in accordance with NFPA 101 19.2.2.2.6. This deficient practice affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/11/2010, Surveyor 12316 observed at 2:58 pm that two doors of the Storage Rooms S028 and S029 in the Basement were mechanically held open and not with electro-magnetic held open devices that release the doors upon activation of the fire alarm or sprinkler system in accordance with the requirements of NFPA 101 19.2.2.2.6 and 7.2.1.8.2. Such held open devices do not automatically release and close the doors to prevent smoke transfer from the storage rooms into corridor in the event of fire.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer on 2/11/2010 at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to the failure of one smoke barrier to extend to the roof deck above in accordance with the NFPA 101 19.3.7.3 and 8.3 requirements. This deficient practice affected 2 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), Staff E (environmental safety officer), and Staff J (electrician) on 2/9/2010, Surveyor 12316 observed at 11:45 am that the smoke barrier located adjacent to the Gift Shop and the Orthopaedics Plus on the 1st Floor did not fully extend to the roof deck above, and the portion of smoke barrier wall in the interstitial space was not 1/2 hr fire-rated as required.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, environmental safety officer and electrician at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to the failure of one fire-rated smoke barrier door located on the 2nd floor to fully close. This deficient practice affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/9/2010, Surveyor 12316 observed at 1:15 pm that the west leaf of a pair of smoke doors did not fully close and latch, and left a gap of ¾ inch at the meeting edge. The ¾ hr fire-rated door in the 1-hr fire-rated smoke/fire separation wall between Theda Clark Medical Center and another hospital, is required to close and latch.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to failure to protect openings in hazardous areas in five locations with properly functioning doors in accordance with NFPA 101 19.3.2.1. This deficient practice affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), Staff E (environmental safety officer), Staff G (business unit manager), and Staff H (RN, supervisor) on 2/9/2010, Surveyor 12316 observed at 3:59 pm that the Storage Room R137A located across the Decontamination Room in the Operation Room (OR) Suite on the 1st Floor did not latch when tested.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to failure to protect openings in hazardous areas in four locations with properly functioning doors in accordance with NFPA 101 19.3.2.1. This deficient practice affected 4 of 29 smoke compartments in the facility.

Findings include

Item 1. During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2:25 pm that the Storage/Condensate Pump Room in the Orthopaedics Room Suite on the 1st Floor did not have a self-closing device as required. The condensate pump room was also observed to have been used as a storage room;

Item 2. During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2:50 pm that the Storage Room N115B with one work station adjacent to the Gift Shop on the 1st Floor did not have a self-closing device as required;

Item 3. During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 3:48 pm that the Supply Room N145 in the Cath Lab Suite on the 1st Floor did not have a self-closing device. The room had combustibles stored in it and hence was deemed hazardous; and

Item 4. During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/11/2010, Surveyor 12316 observed at 3:50 pm that the fire-rated door of the Medical Records Storage Room N034 in the Basement did not latch due to obstruction caused by the flooring material (carpeting) over the door sill. The combustible carpeting on the fire-rated door sill does not meet the requirement of NFPA 80 1-11.2.4, which requires a sill of noncombustible material.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to one non-latching fire-rated door of the Gift Shop Storage on the 1st Floor in accordance with NFPA 101 19.3.2.5. This deficient practice affected 1 of 26 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2:40 pm that the 1 ½ hr fire-rated door of the Gift Shop Storage on the 1st Floor did not latch as required.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to the failure of one fire-rated door on the 1st Floor to latch in an exit passageway. This deficient practice affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 1:15 pm that a pair of 1 ½ hr fire-rated doors located adjacent to the S128 Room did not latch. The double doors protected an opening in the exit passageway enclosure located between the ICU suite and OR suite.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to (i) failure to maintain one exit access to exits readily accessible in the 3rd Floor near the Birthing Center on the 3rd Floor, and (ii) lack of required headroom of minimum 7 ft in the Medical Records Room and adjacent corridor. This deficient practice affected 1 of 29 smoke compartments in the facility.

Findings include

Item (i). During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/11/2010, Surveyor 12316 observed at 1:20 pm that a pair of ¾ hr fire-rated cross-corridor smoke doors located in Corridor N301 near the Birthing Center on the 3rd Floor had delayed egress locks installed on both doors, and were not operable when tested by a push on the door.

The above stated pair of fire-rated doors in 1 hr smoke barrier wall were not arranged to be readily opened in accordance with the NFPA 101 7.2.1.5 and 7.2.1.5.4 requirements. Hence, the doors in the means of egress Corridor N301 did not readily provide an access to exit stairwells as required. Furthermore, there was no proper 15 second delayed egress signs posted on the doors in accordance with NFPA 101 7.2.1.6.1

Item (ii). During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/11/2010, Surveyor 12316 observed at 3:48 pm that the headroom (ceiling height) in the Medical Records Storage Room with some staff work stations, and in the corridor outside of the records storage room was approximately 6 ft 8.5 in. and not 7 ft as required by NFPA 101 7.1.5 Exception No. 1. The lack of required headroom does not ensure a safe egress from the room and corridor.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to higher than required temperature rated sprinkler heads in the Mechanical Room located above the 1963/69 Building. The temperature rating of sprinkler heads did not conform to the requirements of NFPA 13 5-3.1.4.1 1999 edition. This affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/11/2010, Surveyor 12316 observed at between 11 am and 11:30 am that the Mechanical Room located in the penthouse above the 1963/69 Building was not protected with sprinkler heads of ordinary temperature rating.

The penthouse contains air-handling units, ductwork, circulating pumps, steam piping with no exposed steam mains, or unit heaters, some related combustible storage, such as air filters, and electrical switches and panels. The quantity of combustibles in the room is not moderate or high to classify the room as an ordinary hazard group per NFPA 13 2-1.2, which would have allowed intermediate or high-temperature rated sprinkler heads.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to failure to maintain a minimum of 18 inch vertical clearance below the sprinkler deflectors and above the top of storage in two storage rooms in accordance with NFPA 13 5-5.6 1999 edition. This deficient practice affected 2 of 29 smoke compartments in the facility.

Findings include

Item (i). During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 1:12 pm that the vertical distance from top of storage and sprinkler deflectors in the Clean Equipment and Supply Room in the ICU suite on the 1st Floor was less than 18 inch.

Item (ii). During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2:40 pm that the vertical distance from top of storage and sprinkler deflectors in the Gift Shop Storage on the 1st Floor was less than 18 inch.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with the Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients due to storage of compressed oxygen gas cylinders along with other incompatible materials in a housekeeping closet, and not stored in accordance with NFPA 99 8-3.1.11.2. This affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2 pm that two " E " size compressed oxygen gas cylinders were stored with other non-related materials and combustible items in the Housekeeping closet in the Outpatient Prep/Recovery Suite on the 1st Floor.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with the Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and staff interview, the facility failed to install a floor drain in the emergency shower located inside the Laboratory in accordance with NFPA 99 10.6. This affected 1 of 29 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 2:55 pm that the emergency shower installed in the Laboratory did not have a floor drain to drain the water in the event of emergency use of the shower. The Lab is located in the Basement.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with the Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observation and staff interview, the facility failed to label the emergency electrical wall outlets in two locations in the ICU Suite in accordance with NFPA 70 517-19(a), and to provide working space in front of electrical switches in one location in accordance with NFPA 70 110-26. This affected 1 of 29 smoke compartments in the facility.

Findings include

Item (i). During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/10/2010, Surveyor 12316 observed at 12:52 pm that the electrical duplex receptacles in two rooms S100 and S103, where critical care is provided to patients, were not identified as to which critical branch electrical panel and circuit breaker the power is supplied from.

Item (ii). During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) on 2/11/2010, Surveyor 12316 observed at 11 am that the Mechanical Room with electrical panel and switches, and air-handling units serving the hospital had one cart with a saw stored in front of electrical switches. The object did not provide working space required in front of electrical panels and switches in accordance with NFPA 70 110-26. The Mechanical Room is located in the penthouse above the 6-story 1963 Building.

The above two observations were acknowledged by Staff C, Staff D, and Staff E at the time of discovery, and confirmed with the Staff B (facility management manager), Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

NFPA 70 110-26.
"Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment ... "

NFPA 70 110-26(b) Clear Spaces.
"Working space required by this section shall not be used for storage ..."